(134) Long-Acting Injectable Buprenorphine: A Vein-Saving Victory in Pediatric Case

Background & Introduction: Overdose deaths among adolescents have steadily risen since 2019 and now constitute the third leading cause of death in the pediatric patient population.[1] Adolescent drug use is associated with an increased risk of mental health comorbidities, and the majority of adolescents with severe substance use disorder (SUD) at age 18 will continue to have symptoms of SUD into adulthood.[1] Despite these statistics, a retrospective cohort study of 3,791 adolescents found that only 1 in 54 received evidence-based pharmacotherapy following an opioid overdose.[2] Such research further highlights the overall lack of utilization of pharmacotherapy in adolescents with opioid use disorder (OUD). Although current literature is limited, several case reports have described the use of opioid agonist therapy (OAT) in the pediatric population. Further, buprenorphine extended-release injections are not Food and Drug Administration-approved for pediatric patients, and the literature is even more limited in this patient population [3]. Here we present a case utilizing OAT with sublingual buprenorphine which was transitioned to long-acting injectable buprenorphine (LAIB) in a high risk 15-year-old male with severe OUD. This patient's care required cross-state coordination of care between a local community hospital and a tertiary pediatric hospital in Michigan.

Case Description: A 15-year-old male presented to the emergency department with constipation, urinary retention, and a weight loss of 35 lbs over the previous 2 months. UDS was positive for fentanyl and patient reported that he had started taking oral opioids, transitioned to snorting opioids, then transitioned to IV use, using approximately 0.1 g fentanyl total via up to 8 injections daily for the past year. He was admitted to the tertiary pediatric hospital where he was treated for constipation and started on sublingual buprenorphine. On outpatient follow-up he was found to have continued IV fentanyl use and had discontinued sublingual buprenorphine over fear of precipitated withdrawal. He was noted to have tachycardia and intermittent chills and lab review from his recent hospitalization showed markedly elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). He was sent back to the emergency department with concern for sepsis and supervised re-initiation of buprenorphine given his concern for precipitated withdrawal. He ultimately required readmission to the tertiary pediatric hospital and was found to have septic thrombophlebitis with blood cultures positive for Enterococcus, Enterobacter, Pseudomonas putida and Stenotrophomonas maltophilia. He was treated with 6 weeks of IV antibiotics while being re-initiated on sublingual buprenorphine, titrating up to 8 mg of buprenorphine/naloxone (sublingual) daily. Discharge planning involved discussion with the patient and his guardian, the patient’s local addiction medicine team, and the addiction medicine team affiliated with the tertiary pediatric hospital. Based on inter-team and patient discussions, the care was coordinated to have him receive LAIB at 300 mg dose the day of hospital discharge through the addiction medicine team affiliated with the tertiary pediatric hospital. His LAIB was then continued near home through his local addiction medicine team. Following discharge the patient continues to follow with local addiction medicine and remains on LAIB now at 100 mg every 26-30 days. While the patient has had lapses using full agonist opioids, he reports that overall LAIB minimizes cravings and has provided significant benefit. He has returned to school and has continued to follow regularly with outpatient primary care for his other medical issues. He has not had any acute care medical visits and denies injection drug use since starting on LAIB.

Conclusion & Discussion: This case represents additional data on the impact of LAIB on pediatric patients. LAIB is FDA-approved for patients >16, but there is limited data on this population. Adolescents represent a high-risk population where substance use disorder is undertreated and often is delayed in diagnosis. Pediatricians may have limited experience in diagnosing and managing substance use disorders while adult addiction medicine specialists may have less familiarity with the unique developmental needs of pediatric patients. In addition to the delayed diagnosis of substance use disorder, this patient also had a delayed diagnosis of bacteremia and thrombophlebitis. In this case informed consent with the patient and guardian was emphasized for a collaborative approach designed to foster patient autonomy and engagement in the treatment plan, which are crucial factors for successful outcomes in adolescent care. Adolescent medication adherence can be challenging, and parental monitoring of compliance can be difficult. Long-acting injectable medications offer improved adherence by ensuring consistent therapeutic levels and providing parents with greater peace of mind knowing their child is receiving the necessary treatment. As awareness of OUD grows in this population, this case highlights the necessity for continued innovative treatment strategies to address the unique needs of pediatric patients.

References: 1. Hadland, S.E., et al., Receipt of Timely Addiction Treatment and Association of Early Medication Treatment With Retention in Care Among Youths With Opioid Use Disorder. JAMA Pediatr, 2018. 172(11): p. 1029-1037.

2. Lai, B., et al., Adolescent Substance Use Disorder in Primary Care: Challenges in Treatment Referral Beyond Access Availability. J Prim Care Community Health, 2024.15: p. 21501319241276817.

3. Schmuhl, K.K., A. Golec, and A.M. Ebersole, Early Remission of Opioid Use Disorder in an Adolescent Using Buprenorphine Extended - Release Subcutaneous Injection: A Case Report. J Adolesc Health, 2024. 75(1): p. 200-202.